Form Dwc 11 C PDF Details

In the realm of workers' compensation in Rhode Island, the DWC 11 C form serves as a pivotal document for certain corporate officers who wish to opt into the protections offered by the state's workers' compensation statutes, specifically outlined in Title 28, Chapters 29 through 38. This form is exclusively applicable to individuals who have been appointed as corporate officers between January 1, 1999, and December 31, 2001, and who were not previously employees of the corporation. By completing this form, corporate officers formally declare their intention to become subject to the provisions of Rhode Island's Workers Compensation Statute, thereby extending coverage to scenarios that might not automatically apply to their positions. The process requires the officer to provide personal information, including their Social Security number, date of birth, and corporate title, along with the business details such as name, address, and Federal Employer Identification Number (FEIN), and the relevant insurance information. Moreover, the officer acknowledges the seriousness of the document through a declaration under the penalties of perjury that the information provided is accurate and complete. The requirement of a notary public’s signature further underscores the document’s legal importance. With a nominal filing fee, the DWC 11 C form submission process also involves specific steps for retention and sharing of the document among the corporate officer, the insurance company, and the Rhode Island Department of Labor and Training, ensuring all parties are informed of the election. This procedure not only formalizes the officer's coverage under workers’ compensation law but also highlights the state’s regulatory framework designed to protect workers at all levels within a corporation.

QuestionAnswer
Form NameForm Dwc 11 C
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDBA, Insurer, DWC-11-C, TDD

Form Preview Example

State of Rhode I sland, Department of Labor and Training, Workers’ Compensation Unit

P.O. Box 20190, Cranston, RI 02920-0942

Phone (401) 462-8100 TDD ( 401) 462-8006

ELECTI ON BY EXEMPT CORPORATE OFFI CER TO BECOME SUBJECT TO W ORKERS’ COMPENSATI ON

( TI TLE 2 8 CHAPTERS 2 9 t hrough 3 8 )

** * * THI S FORM ONLY APPLI ES TO ANY PERSON W HO W AS APPOI NTED A CORPORATE OFFI CER

AND W AS NOT PREVI OUSLY AN EMPLOYEE OF THE CORPORATI ON

BETW EEN 1 / 1 / 1 9 9 9 AND 1 2 / 3 1 / 2 0 0 1 * * * *

I,

 

 

Name

 

Soc. Sec. No.

Address

 

Date of Birth

 

 

Corporate Title

an officer of the following business,

 

 

 

Name

 

DBA

 

Address

 

FEIN

 

 

 

I nsurer

 

 

 

I nsurance Policy #

 

do hereby give notice in writing that I elect to become subject to the provisions of the Rhode I sland Workers’ Compensation Statute (Title 28 Chapters 29 through 38) .

Under penalties of perjury I declare that I have examined this form and to the best of my knowledge it is true, correct and complete. I further acknowledge that false statements on the within document may subject me to criminal prosecution.

Signat ure _________________________________ Not ary Public Signat ure __________________________

Dat e _____________________________________ Dat e Commission Expires _________________________

A filing fee of five dollars ($5.00) is required with the submission of this form. Please enclose a check or money order payable to Rhode I sland Department of Labor and Training. The employer should retain a copy of this form, send a copy to the insurance company and send an original to the Department of Labor and Training. For a dated, receipt copy, include a copy with the original sent to the Department of Labor and Training with a SELF-ADDRESSED, STAMPED ENVELOPE. The original and copy will be date stamped. The original will be retained for our files. The stamped copy will be returned in the envelope provided.

D W C-11-C ( 1/ 2002)

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